Remarks by Carolyn
Clancy, M.D., Director of the Agency for Healthcare Research
and Quality
The
Office of Minority Health National Leadership Summit on
Eliminating Racial and Ethnic Disparities in Health, January 9, 2006
Thank you, Garth, for the kind words and thank
you for the opportunity—and the honor—to be a part of the Office
of Minority Health's National Leadership Summit on Eliminating Racial and
Ethnic Disparities in Health. I've been looking forward to this event for
a long time, and the chance to see so many of my friends and colleagues
who have been working so hard on the issues being addressed at this summit.
One of the most valuable things about a being
at a summit is perspective—having a clear vantage point to look at where
we've come from, to look around and see where we stand today, and to look
ahead to see where we're going. With that in mind, I'd like to focus on three
areas this morning:
- The foundational role of the Heckler Report
in bringing us to where we are today.
- AHRQ's release today of the third annual
National Healthcare Quality Report and Disparities Report, and how we're
doing as a nation to improve quality and eliminate disparities.
- And finally, I'd like to talk to you about
the opportunities we have to use these measures, and build on a range of
promising initiatives, to improve health outcomes for all Americans.
It is altogether fitting and
proper that this summit is commemorating the 20th anniversary
of the "The Secretary's Report on Black and Minority Health," presented
by then Secretary of Health and Human Services, Margaret Heckler. Before
that, she was my congresswoman from the Commonwealth of Massachusetts. In fact, a strong case can be
made that this summit, and the National Healthcare Quality and Disparities
Reports, owe their origins to the legacy of the Heckler report, and the
awareness it raised.
In historic terms, the 1980s were not that
long ago. Recollections of key events that led to the development
of the Heckler Report are still vivid. There are people here today who contributed
to the report and remember standing in Secretary Heckler's conference room,
when she was briefed by staffers on a draft of the 1984 "Health-United
States" report. After reviewing the report, which contained
presentations of very statistically different data under the headings "White",
"Black" and "Total," Secretary Heckler asked, "Why are these differences
so consistent and so large?" Her briefers were momentarily
taken aback. They paused for a moment and then someone explained,
"It's always been that way."
But thanks to the Heckler Report, we finally
had a clear starting point and the outline for a roadmap to change things. Our national dialogue on disparities began
to be informed by research, and supported by a growing commitment, not
only measure disparities, but to find out why they occur and how they can
be eliminated.
I have been fortunate, as a health services
researcher, to have many opportunities to study the causes, effects and
implications of racial, ethnic and socioeconomic disparities in American
health care. But as a medical doctor, my interest in wanting
to understand and eliminate disparities was inspired by my experience with
patients—and I remember one in particular.
Early on in my residency in Massachusetts,
I was working in the emergency department and saw a female patient who
was suffering from severe abdominal pain. She didn't speak
English, and had a friend translating my questions into Spanish. I kept asking her, in as many ways as I could,
"are you taking antacids?" I went up and down the list of
over-the-counter brands and she kept shaking her head "no, no, no".
She finally returned home to wait for her
lab tests. When the tests came in, it was clear that she
needed to come back to the hospital. However, she did not
have a phone. So the next morning, after my shift, I went
to her home with a Spanish-speaking nun to ask her to return to the hospital.
And from the moment we walked in her door, we saw bottles and bottles of
Mylanta everywhere. There must have been over 40 bottles
in her home, visible to me.
That experience gave me first-hand knowledge
about how barriers in language and culture can stand between a patient
and the care they need, despite everyone's best intentions. There I was, with all the resources of a
teaching hospital, but unable to get to the underlying issue. It
was frustrating, but it motivated me, as it has so many clinicians and
researchers, to study the factors that create disparities.
Today, we have ways to measure the quality
of patient-provider communication, as well as a broad array of other measures—179 in all—that measure quality and disparities in four key areas:
effectiveness, patient safety, timeliness and patient centeredness. And you will find them all in the third annual National
Healthcare Quality and Disparities Reports, which were literally printed
over the weekend. In fact, they arrived with me this morning. So, let's take a look at some of the highlights
and implications of the 2005 Reports.
During the last year, the overall quality of U.S. health
care improved at the rate of 2.8 percent, the same rate of improvement
shown in last year's National Healthcare Quality Report. In 44 core quality measurement categories, 23 improved,
19 were unchanged and only two became worse. Nevertheless, the 2005 report shows that there has been
much more rapid improvement in some measures, especially where there have
been focused efforts to improve performance. For example, measures for heart attack, heart failure
and pneumonia showed an annual improvement of 9.2 percent. These
are priority areas for Medicare, where hospitals have received special
help from Medicare's Quality Improvement Organizations.
The 2005 National Healthcare Disparities Report finds
that significant disparities between whites and minorities continue, with
some signs of improvements. In measures related to the quality of care, more racial
disparities were narrowing than widening. For
example, rates of late stage breast cancer decreased more rapidly among
black women than among white women resulting in a narrowing of the disparities. Treatment
of heart failure improved more rapidly among American Indian Medicare beneficiaries
than among white Medicare beneficiaries.
Despite these trends, blacks received poorer quality
of care than whites in 43 percent of the core measures, and American Indians
and Alaska Natives received poorer quality of care than whites in 38 percent
of measures. In access to care, we saw reductions in most racial
disparities affecting blacks, Asians, and American Indians and Alaska Natives.
However, this trend has been reversed for Hispanics,
where we saw disparities in quality and access to care growing wider in
a majority of areas. Only 41 percent of quality disparities were narrowing
for Hispanics, while 59 percent were growing larger. The
report also indicated that disparities were growing for most measures related
to access. For
example, the quality of diabetes care declined among Hispanic adults as
it improved among white adults. In
addition, the quality of patient-provider communication (as reported by
patients themselves) declined from among Hispanic adults as it improved
among white adults. Access
to a usual source of care increased more slowly among Hispanics than among
whites.
Overall, the Disparities Report shows that low-income
people, regardless of race or ethnicity, experienced many of the largest
disparities health care quality and access.
In many areas, we know the specific treatment steps
and procedures to take for quality improvement. We know what
to do. The challenge continues to be make sure everyone in
the health care system knows what to do, and is making it part of their
everyday practice. We've seen that public reporting is a powerful
tool for improvement. The public reports coming from Medicare's Hospital
Quality Initiative have been very useful in this area.
Another great example of the power of the
spotlight was reported last year in the New England Journal of Medicine. The
study examined trends in the quality of care and racial disparities for
Medicare beneficiaries in managed care plans. The health plans were required to report
on the quality of care they provided according to the HEDIS [Health Plan Employer Data and Information Set] measures. When
the study began, the early data indicated that blacks received of lower
quality care than whites. However, after seven years of publicly reporting
performance through HEDIS, the health plans' clinical performance improved
substantially on all measures. Gaps in quality associated
with patient race narrowed in seven of the nine measures. And because of public reporting by nursing
homes, the 2004 National Healthcare
Quality Report indicated that their quality is improving steadily.
We have a mixed record of success in improving quality
of care in our Nation and reducing health care disparities. While we find improvements in quality and access on
a wide front, it is inconsistent, and the need for action to improve quality
of care for all Americans is as great as ever. In addition, what we're seeing is an enormous opportunity
not only to close the gap in health care disparities, but to improve the
overall health of all populations. These are inextricably linked.
Too much of a focus on specific populations or measures
can take our eyes off of the big picture. We need to be bold,
ambitious and imaginative as we set improvement goals for all of our citizens. The bottom line is that we are seeing modest improvement
in quality and an overall narrowing in disparities for most racial groups. But
much more is needed—no measures were at optimal levels for anyone. This
is especially for Hispanics, where we need to turn the trend around.
So what are some of the implications of these reports? How
can we use these measures, build on the progress we're making, and keep
moving forward?
As a researcher, I can appreciate how far we've come
during the last few years we've worked on these reports. Our
knowledge base is growing and our measurement tools are getting more powerful. But as these tools get better, we recognize that we
still need to get better information. There are still significant
gaps in reporting racial and ethnic disparities at the state level, and
at the health plan level.
In particular, we need much better information at all
levels on Hispanic sub-groups, especially related to language and dialect. We also need to collect and analyze more
racial and ethnic data from health plans and insurers so this data can
be used to improve patient care.
According to a 2004 report from America's
Health Insurance Plans, almost half of health plan enrollees surveyed belong
to a health plan that does not collect data on race and ethnicity. This
information gap needs to be closed if we are going to fully understand
the scope of this challenge.
We also need to include the study of priority populations in more of
our research to increase our knowledge base. At AHRQ we're
addressing this need by asking all of the researchers we support to consider
and include priority populations in their studies wherever feasible.
Good data and good measurements are important, because what you can't
measure, you can't change. We need benchmarks and signposts
along the way to show how we're doing. But reports alone
cannot produce results. But we can't wait. We need to do what
we can to eliminate disparities now. We
need to design and test interventions that address the disparities we find. We need to change our focus from documenting
gaps in care to finding ways to close the gap. Moreover, our efforts to
do so are likely to yield additional scientific insights.
The
key to these efforts is collaboration, and there are many great examples
of partnerships out there. One of the most far-reaching is
the National Health Plan Collaborative to Reduce
Disparities and Improve Quality in Diabetes Care.
Nine
of the nation's largest health insurance plans have joined together to
improve the capacity to collect and analyze data on race and ethnicities. These
data are linked to quality measures, and they are developing quality improvement
interventions to close gaps in care. Along
with the Robert Wood Johnson Foundation, the Center for Health Care Strategies
and the Institute for Healthcare Improvement, AHRQ is helping to fund and
guide this collaborative. It
is doing vitally important work to close the gap in the quality of diabetes
care for African Americans, Hispanics and Native Americans.
As
you may know, these populations have higher rates of diabetes-related complications
—in some cases as much as 50 percent greater than the total population. One of the most
impressive aspects of this collaboration is that the leaders of these health
plans came to us even before the first National Healthcare Disparities
Report was published.
A
unique feature of this collaborative is that the plans commit to improve
and share their results with each other. For them this is
not 'research' or a 'demonstration' but core business. It's
a model for an action-oriented approach to a pervasive problem in health
care.
The
bottom line is that when it comes to disparities, we simply don't have
the luxury or the time to fund long-term 'definitive' studies. As
public and private entities work together and share ideas and resources,
we can test different approaches, learn as we go, and share what we learn.
The growing commitment
by health insurers and employers, and the work of many disparities-related
collaboratives are making a difference, not only nationally, but locally. It's at the local
and community level where we have the most opportunity to make lasting
progress. And as more organizations learn about these tools,
it's no longer a matter of "pushing" them out to the field, but meeting
the increased "pull" or demand, and that's a challenge we eagerly accept.
That's why we
support community-based research and share our research tools at the county
and state level, and work with so many local health plans and non-governmental
organizations. It's why we work with HRSA and have seen so
much success with its initiatives. We
know that it is essential to have good measures and reporting tools at
the national level, so we can inform policy, see trends, and know where
we're going as a country.
But
for the average person, on a day-to-day basis, population level analyses
at the national or State levels are pretty abstract. To paraphrase
another popular saying in this town, "All health care is local".
Communities
that use the powerful measurement tools we have developed for the National
Healthcare Quality and Disparities Reports consistently are going to be
able to gather disparities-related information much more efficiently than
we can at the Federal level. It will be much more meaningful
to them.
Through
these reports, and the resources behind them, we're dedicated to making
these standardized tools available at the grass roots level for the benefit
of each community, and for the benefit of the nation as a whole. We're
going to do as much as we can to promote the National Healthcare Quality
and Disparities Reports. We
will raise awareness and continue the sense of urgency and purpose to all
the work being done to eliminate disparities across our country.
We can never
underestimate the importance of awareness for this issue, or fail to see
the importance of disparities in personal terms and its impact on the fabric
of American communities. Disparities are more than facts
and figures. They have a human face, a uniquely American
countenance.
So where do we
go from here? Where are we on the journey to our common destination,
an America where health outcomes are getting better for all of our citizens? From
the standpoint of this summit, I can see four milestones on our roadmap
for quality improvement and the elimination of disparities.
The first milestone
was the Heckler Report and developing the research wherewithal and commitment
to measure disparities.
The next milestone,
in my opinion, was an AHRQ-supported study that came out of Georgetown
University in 1999. In this study, physicians watched videos
of white and minority actors portrayed patients with identical symptoms
for a heart problem. They were less
like to prescribe evidence-based diagnostic procedures for older African
American women. As you can imagine,
the results of this study had an enormous impact within the physician community,
and started a very productive dialogue.
The third milestone
is actually a series of many milestones in health services research, reflecting
our increased commitment as a nation to study the causes of disparities,
and target more research funding in this area.
And the fourth
milestone is being built all around us, through public-private collaboration,
as we translate our growing body of research into practice, and develop
effective interventions to eliminate disparities. Our goal is to
reduce disparities in health by providing the highest possible quality
of care for all of our citizens, and with every step we take together,
we're getting closer to this goal, and we can never lose sight of this
common destination.
Whether you study
the reports, study the faces of our fellow citizens or study your own heart,
it becomes clear that eliminating the disparities in health care is one
of the most important things we can do as a nation to improve the overall
quality of American health care.
To make further
improvements in quality of care and respond to a more demographically diverse
population, we need to bridge the gap on disparities. And
because of the energy and enthusiasm of the people in the room, and the
people you represent, I'm confident we can do it.
Now more than
ever, the quality of healthcare is intertwined with the commitment to eliminate
disparities. It reminds me of something Dr. Martin Luther
King, Jr. said many years ago, but seems to be even more appropriate for
today's discussion. Dr. King said,
"We are caught in an inescapable network of mutuality, tied to a single
garment of destiny. Whatever affects one directly affects
all indirectly."
In this spirit
of connectedness and cooperation, let us continue our work, so that the
day will come when all we need is a National Healthcare Quality Report,
and the Disparities Report is no longer necessary. Thank
you very much.
Current as of January 2006
Internet Citation:
Highlights and Implications from the Findings of the National Healthcare Quality Report and Disparities Report. Speech by Carolyn M. Clancy, Office of Minority Health National Leadership Summit on Eliminating Racial and Ethnic Disparities in Health, January 9, 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/sp010906.htm
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